Clinical Supervision Form (LeAnn Jean LPC, CPCS, MAC)

This form is to be used for Clinical Supervision under the direction of LeAnn Jean, LPC, CPCS, MAC.

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Time In:
:
Include the start time of your clinical supervision meeting.
Time Out:
:
Include the end time of the clinical supervision meeting.
Based on your time-in and time-out time Include the total time you were in the clinical supervision meeting.
Modality:
Location:

Clinical Supervisor Signature, LeAnn Jean LPC, CPCS, MAC

Sign (include Credentials) and date below.
Write A Note
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Counselor Signature

Sign (include Credentials), print name (include credntials) and date below.
Printed Name and Credentials of Counselor
Write A Note
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